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Carolyn J Presley
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EP1.12 - Small Cell Lung Cancer/NET (ID 202)
- Event: WCLC 2019
- Type: E-Poster Viewing in the Exhibit Hall
- Track: Small Cell Lung Cancer/NET
- Presentations: 1
- Now Available
- Moderators:
- Coordinates: 9/08/2019, 08:00 - 18:00, Exhibit Hall
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EP1.12-38 - Retrospective Analysis of Immunotherapy Utilization in Advanced Small Cell Carcinoma at an Academic Cancer Center (Now Available) (ID 2520)
08:00 - 18:00 | Author(s): Carolyn J Presley
- Abstract
Background
Small-cell carcinoma (SCC) is an aggressive neuroendocrine carcinoma which commonly originates in the lung (SCLC). In contrast to non-small cell lung cancer (NSCLC), immunotherapy (IO) utilization has been limited for SCLC. Nivolumab was approved as a single agent in 2018 for third-line therapy. In 2019, the IMpower133 trial led to approval of first-line chemo-IO (atezolizumab plus carboplatin and etoposide) for extensive-stage SCLC. Despite these approvals, there is limited data about experience utilizing IO in SCC outside of clinical trials, including patterns of care, survival, and incidence of brain metastases. We therefore conducted a retrospective review of IO utilization at an academic cancer center in the United States.
Method
Institutional pharmacy database was used to perform an unstructured data collection of medical record numbers based on SCC diagnosis and IO treatment codes between January 1, 2008 and October 1, 2018 at The Ohio State University Medical Center. Patient data was then abstracted from the electronic medical record. Variables included demographics, co-morbidities, stage, metastatic sites (including brain), treatment history (including chemotherapy, IO and radiation), and treatment response. Survival from the start of IO to death and median overall survival (OS) from diagnosis to death were calculated.
Result
Forty patients, 17 women and 23 men, were eligible for evaluation. The median age was 64 years (30-91 yo); 36 patients were current/former smokers. At diagnosis, most were extensive-stage (65%). Common metastatic sites at diagnosis included brain (20%), bone (35%) and liver (33%). Overall, 22 patients (55%) developed brain metastases over the course of disease. Median line of IO was 2nd line (range 2nd-5th line); nivolumab-ipilimumab was the most common regimen (43%), followed by nivolumab (38%), then pembrolizumab (20%). Patients received an average of 4 cycles of IO (range 1-35). Nine patients were treated on clinical trial. Median survival after IO was 4.2 months and median OS of 17.3 months. Median survival for patients with brain metastases was 2.2 months vs. 10.3 months without (P=.01). Most patients had no durable response to IO; however, responses were observed in 7 patients (1 CR, 6 PR) and 8 patients had stable disease.
Table 1: Treatment Summary Treatment
Patients – no.
Chemotherapy – any line
Carboplatin
28
Cisplatin
15
Etoposide
40
Topotecan
19
Irinotecan
23
Paclitaxel
11
Gemcitabine
1
Immunotherapy
Nivolumab-ipilimumab
17
Nivolumab
15
Pembrolizumab
9
Radiation Therapy
Radiation (non-CNS site)
36
Radiation (CNS)
24
Type of CNS radiation
Prophylactic Cranial Irradiation
8
Whole brain radiation (therapeutic)
16
Gamma knife/stereotactic radiation
6
This retrospective review describes our experience utilizing IO in advanced SCLC at our academic institution. Although treatment patterns are changing with first-line IO, this data reflects the variability of patient responses. Several patients had prolonged responses, indicating potential areas of further investigation. This data will also be used to evaluate IO activity in CNS disease.
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MA24 - Initiatives to Improve Health in Lung Cancer Patients (ID 354)
- Event: WCLC 2019
- Type: Mini Oral Session
- Track: Advocacy
- Presentations: 1
- Now Available
- Moderators:Merel N. Mountain, Nicoleta Mitrea
- Coordinates: 9/10/2019, 14:30 - 16:00, Melbourne (1991)
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MA24.03 - Factors Impacting Patients’ Worries (Accessing Treatment, Treatment Toxicity, & Emotional Burden) Associated with Lung Cancer Treatments (Now Available) (ID 2589)
14:30 - 16:00 | Author(s): Carolyn J Presley
- Abstract
- Presentation
Background
Understanding patient experiences with lung cancer can guide research, treatment, and policy decisions. Conducted as part of a larger study (Project Transform) that aimed to quantified patient experiences, we sought to study the primary concerns of lung cancer patients and their caregivers and to determine what demographic and clinical factors impact these worries.
Method
Lung-cancer worries were identified from patient interviews and the literature. A novel an instrument assessing 13 potential worries on a 3-point importance scale was incorporated as part a national survey of lung cancer patients (inclusive of all types/stages of disease) and caregivers recruited through LUNGevity Foundation. Factor analyses was used to identify key constructs among the 13 worries. We then explored variation in the standardized factor scores across demographic and clinical indicators collected in the survey.
Result
Of the 426 participants in the survey, there were 385 patients and 41 caregivers. The average age of respondents was 58.9 years, 54% earned less than $75,000 per year, and 67.6% had completed college. Three factors were identified associated with worrying: 1) “accessing treatments” (incorporating knowledge, communication, access); 2) “treatment toxicity” (incorporating both side-effects and financial impact); and 3) “emotional burden” (including worries about dying, emotional toll, and being a burden), with Cronbach’s alphas of 0.89, 0.73, and 0.74 respectively. Worries about accessing treatment were lower among NSCLC (P=0.006), presence of MET mutations (P = 0.027) and those not currently receiving therapy (P=0.033). Worries about treatment toxicity were higher among non-white (P<0.001), non-retired (P<0.001), those earning less than $75,000 (P<0.001), younger patients (P<0.001), and those with ALK (P=0.026) or HER2 (P=0.041) mutations. Worries about treatment toxicity were lower among patients on Medicare or Medicaid during treatment (P = 0.023) and NSCLC patients (P=0.018). Worries about the emotional burden of treatment were lower among those >=60 years (P=0.002) and those who are retired (P=0.021) and higher among those having surgery (P=0.039).
Table 1: Marginal effects of patient factors on standardized worry scores
Factor
Accessing Treatment
Treatment toxicity
Emotional burden
Patient
-0.052 (0.16)
-0.144 (0.16)
-0.224 (0.16)
Age >= 60
-0.1 (0.1)
-0.336 (0.1)***
-0.309 (0.1)**
Female
0.003 (0.12)
0.239 (0.12)
0.158 (0.12)
Non-white
-0.022 (0.16)
0.56 (0.16)***
0.048 (0.16)
Hispanic, Latino, or Spanish
-0.003 (0.22)
0.233 (0.22)
0.161 (0.21)
Primary Language - Spanish
0.116 (0.7)
0.879 (0.69)
0.423 (0.67)
Armed Forces
-0.103 (0.18)
-0.134 (0.18)
0.055 (0.18)
Marries
0.139 (0.11)
-0.177 (0.11)
0.073 (0.11)
Has children
0.004 (0.13)
-0.031 (0.13)
0.203 (0.12)
College or professional degree
0.208 (0.11)
-0.096 (0.11)
-0.104 (0.1)
Retired
-0.048 (0.1)
-0.488 (0.1)***
-0.233 (0.1)*
Household Income < $75,000
0.031 (0.11)
0.376 (0.11)***
0.025 (0.11)
Population < 2,500
-0.168 (0.22)
-0.099 (0.22)
0.193 (0.21)
Chronic conditions as diagnosis
-0.078 (0.12)
-0.021 (0.12)
0.146 (0.12)
NSCLC
-0.308 (0.11)**
-0.263 (0.11)*
-0.111 (0.11)
Private Insurance
0.084 (0.11)
0.139 (0.11)
0.057 (0.11)
Medicare or Medicaid
0.02 (0.1)
-0.235 (0.1)*
-0.079 (0.1)
Other Insurance
-0.092 (0.17)
-0.144 (0.17)
-0.128 (0.17)
No Insurance
0.363 (0.58)
0.56 (0.58)
-0.083 (0.58)
Participated in a clinical trial
-0.029 (0.12)
-0.134 (0.12)
0.077 (0.12)
ALK
0.143 (0.14)
0.295 (0.13)*
0.041 (0.12)
BRAF
-0.241 (0.56)
-0.663 (0.55)
-0.345 (0.52)
EGFR
-0.038 (0.13)
-0.109 (0.13)
0.121 (0.12)
HER2
0.689 (0.48)
0.973 (0.47)*
0.439 (0.45)
KRAS
-0.201 (0.21)
-0.067 (0.21)
-0.113 (0.2)
MET
-0.765 (0.34)*
-0.389 (0.34)
0.19 (0.32)
NTRK
0.767 (0.68)
0.467 (0.67)
0.101 (0.63)
RET
0.154 (0.4)
-0.47 (0.39)
-0.69 (0.36)
ROS1
0.149 (0.26)
-0.053 (0.25)
0.202 (0.24)
More than 2 lines of treatment
0.09 (0.1)
0.026 (0.1)
0.03 (0.1)
Chemotherapy
0.019 (0.16)
0.008 (0.16)
0.007 (0.16)
Radiation
0.197 (0.29)
0.339 (0.3)
0.101 (0.3)
Targeted therapy
0.143 (0.1)
0.038 (0.1)
0.129 (0.1)
Immunotherapy
0.124 (0.18)
0.188 (0.19)
-0.125 (0.19)
Surgery
0.454 (0.29)
0.407 (0.3)
0.612 (0.29)*
Angiogenesis inhibitors
0.081 (0.41)
0.101 (0.42)
0.268 (0.42)
No current treatment
-0.214 (0.1)*
-0.192 (0.1)
-0.163 (0.1)
Notes: Standard errors in parentheses, * p<0.05, ** p<0.01, ***p<0.001
Conclusion
Conclusion:
Patients worry to differing extents about accessing treatment, treatment toxicity, and the emotional burden of lung cancer, yet caregivers and patients (on the whole) have similar worries. Lung cancer researchers, clinicians, and policymakers should make decisions in ways that address the heterogeneous experience of patients. Patients worries vary across a confluence of demographic, disease, and treatment factors, hence greater attention to the individual needs of the patient is needed.
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P1.01 - Advanced NSCLC (ID 158)
- Event: WCLC 2019
- Type: Poster Viewing in the Exhibit Hall
- Track: Advanced NSCLC
- Presentations: 1
- Now Available
- Moderators:
- Coordinates: 9/08/2019, 09:45 - 18:00, Exhibit Hall
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P1.01-71 - Bone Metastases and Skeletal-Related Events in Patients with Metastatic NSCLC Treated with ICIs: A Multi-Institutional Study (Now Available) (ID 2421)
09:45 - 18:00 | Author(s): Carolyn J Presley
- Abstract
Background
Skeletal-related events (SRE) occur frequently in patients (pts) with metastatic NSCLC (mNSCLC) and confer a poor prognosis. Data on SRE and the effects of bone modifying agents (BMA) in NSCLC pts treated with immune checkpoint inhibitors (ICI) are limited as is the effect of bone modifying agents (BMA) on development of SRE and overall survival (OS). Here we report the incidence, impact on survival, and risk factors for SRE in pts with mNSCLC treated with ICI in a multi-institutional cohort.
Method
We conducted a retrospective study of pts with mNSCLC treated with ICI at our institutions from 2014 to 2017. Overall survival (OS) was calculated from the date of ICI initiation to death from any cause or last follow-up. Cox regression model was used to study the association between OS and baseline bone metastases (BM). The associations between SRE and categorical outcomes were studied using chi-square/Fisher’s exact test. The study was approved by each institution’s ethics review board.
Result
Table 1. Multivariate survival analysis. Parameter Level Hazard Ratio 95% HR Confidence Limits P-value BM at baseline Absent Ref <0.0001 Present 1.847 1.414-2.413 ECOG 0 Ref 0.0006 1 1.494 1.017-2.196 2 1.506 0.969-2.341 3 3.788 1.442-9.949 Histology Adenocarcinoma Ref 0.969 Squamous 1.057 0.786-1.420 Lines of Therapy 1 Ref 0.0007 2 1.580 1.123-2.223 >=3 2.064 1.417-3.005 We identified a cohort of 330 pts: 259 (72%) treated in second line or beyond; 211 (64%) received nivolumab; median age 63.4; median OS 10.4 mo (95% CI: 8.6, 12.5). In our cohort, 124 (38%) pts had BM at time of ICI, and 43 (13%) developed SRE after ICI (median 2.8 months; 19 pathologic fractures, 1 cord compression, 26 palliative radiation, 8 surgery). Patients with BM at ICI had shorter OS after controlling for ECOG, histology, and line of therapy (Table 1; Hazard Ratio 1.847; 95% CI 1.414 - 2.413; p <0.0001) compared to pts without baseline BM. Development of SRE was associated with presence of BM at baseline but not age, histology, or mutation status (EGFR, KRAS, and TP53). The use of BMA was not associated with OS or decreased risk of SRE. The development of new or progression of existing BM (22% of pts) during ICI was associated with a worse prognosis (mOS 7.1 vs 11.6 mo, p=0.017).
Conclusion
Bone metastases and SRE are a significant cause of morbidity in pts with mNSCLC treated with ICI. The presence of BM at baseline was associated with a worse prognosis after controlling for multiple clinical characteristics. In our cohort, the use of BMA was not associated with decreased risk of developing SRE, osseous progression, or survival.
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P1.16 - Treatment in the Real World - Support, Survivorship, Systems Research (ID 186)
- Event: WCLC 2019
- Type: Poster Viewing in the Exhibit Hall
- Track: Treatment in the Real World - Support, Survivorship, Systems Research
- Presentations: 1
- Moderators:
- Coordinates: 9/08/2019, 09:45 - 18:00, Exhibit Hall
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P1.16-21 - Does Age Affect What Patients Value When Considering Lung Cancer Treatments? Evidence from a National Survey (ID 1947)
09:45 - 18:00 | Author(s): Carolyn J Presley
- Abstract
Background
Few studies have explored how values vary with patients’ lung cancer treatment experience. Due to the rapidly increasing number of treatments for lung cancer, we sought to demonstrate a simple values-elicitation method and explore how values differ across age.
Method
The values of patients and caregivers with small cell (SCLC) and non-small cell lung cancer (NSCLC) inclusive of all stages were explored using a simple values elicitation exercise developed in partnership with diverse stakeholder advisory boards. Respondents were presented with five treatment characteristics, including progression free survival (PFS), short-term side effects (ST-SE), long-term side effects (LT-SE), and mode of administration. All characteristics and plausible outcomes were described. Values were elicited using a simple three-point Likert scale spanning not important, somewhat important, and very important, which were scored as 0, 5, and 10 respectively. Data came from a national survey completed in partnership with LUNGevity and other partners. Differences in values were explored between patients and caregivers, as well as across patients’ self-reported age with two sample t-tests.
Result
Among 793 eligible respondents, 556 were patients (70%) with 77% NSCLC, 11% SCLC, 12% unknown subtype and 233 were caregivers (30%). The average patient age was 58.4 years (y) (SD = 12.3), with 235 (42%) < 60y and 321 (58%) ≥60y. PFS was the most important attribute for respondents, but was undervalued by caregivers compared to patients (mean score (MS): 8.1 v 8.6, P = 0.014). Caregivers overvalued the importance of ST-SE (MS: 7.0 v 6.1, P < 0.001), LT-SE (MS: 8.4 v 7.6, P = 0.001), and mode of administration (MS: 6.9 v 6.1, P = 0.006). PFS was the most important attribute and valued similarly among younger vs. older patients (MS: 8.7 v 8.6, P = 0.76). However, ST-SE (MS: 6.4 v 5.8, P = 0.042) and LT-SE (MS: 8.0 v 7.4, P = 0.018) were more important among patients < 60y vs. ≥60y, respectively.
Conclusion
Among patients with lung cancer, progression free survival was highly valued regardless of patient age. Older patients value short term and long term side effects differently as compared to younger patients.